Patient explanation

Gold standard case presentation

The definition of an upper intestinal bleed is if bleeding occurs above the ampulla of Vater, which is within reach of an upper endoscopy.

A lower gastrointestinal bleed is  subdivided into mid-gastrointestinal bleeding from the small bowel between the ampulla of Vater to the terminal ileum, and lower-gastrointestinal colonic bleeding.

Up to 15% of upper gastrointestinal bleeding (UGIB) are caused by a Mallory Weiss tears or Mallory-Weiss syndrome as it should more accurately be referred to as. The definition of Mallory Weiss syndrome is the occurrence of a mucosa laceration at the junction of the oesophagus and stomach.

UGIB is a common problem with an estimated incidence of around 1/1000 hospital presentations. Excessive drinking leading to recurrent vomiting is the most common cause among chronic alcohol ingestion. In up to 90% of patients, spontaneous resolution occurs and need no more than conservative management.

However, in order to risk stratify patients, the Glasgow Blatchford Score (GBS) is used. There are other scoring systems but this one is the most commonly used due to its use of clinical parameters that are available quickly. The GBS parameters are:

• heart rate
• haemoglobin
• blood urea (due to protein meal from haemoglobin)
• systolic blood pressure on presentation
• reported melaena (not appearance on rectal examination)
• syncope
• history of hepatic disease
• history of heart failure

The GBS should only be used when deciding the need for specific treatments, such as blood transfusion(s), interventional endoscopic therapy or surgical intervention. The score reaches 23 but if scoring zero, hospital admission is not required and hence it has a good sensitivity and negative predictive value.

Other causes of UGIB can be divided into many different areas, whether air vs chronic or via anatomy:

Acute:

• Peptic ulcer disease (most common usually from use of non steroidals such as aspirin)
• Variceal bleeding (from portal hypertension)
• Gastric ulcers
• Duodenal ulcers
• Stress ulcers

Chronic:

• Malignancy of the GI tract
• AV malformations
• Crohn’s disease

There is a geographical difference with East Asians experiencing a stronger association with non-alcoholic cirrhotic disease.

Clinical features:

• haematemesis or coffee ground vomiting
• melaena
• occult bleeding can result in positive faecal occult blood test
• lethargy
• fatigue
• syncope
• angina (sore to cardiac stress from anaemia or haemodynamic instability

Investigations:

Bloods:

• full blood count
• renal function
• liver function tests
• clotting screen
• group and save in the event of blood transfusion
• iron studies
• B12 and folic acid levels

Others

• 12-lead electrocardiogram
• chest x-ray if concerned about Boerhaave’s syndrome (perforation of the oesophagus)
• endoscopy
• colonoscopy
• CT abdomen and pelvis

The Rockall score is used to predict mortality and uses endoscopic findings as part of its scoring system and hence is not useful in the emergency department setting.

For a review of scoring systems and their uses, see this review article.

For a detailed review of upper gastrointestinal bleeding, read this review.